introduction to nm medicaid · call molina. they can tell you if a pa is required and the...

Introduction to NM Medicaid

Conduent

Government Healthcare Solutions

December 14, 2017 Conduent internal use only 2

Resources

When online use: Ask Service Representative

[email protected]

[email protected]

Call Center 505-246-0710 or 800-299-7304

New Mexico Web Portal

• Provider Information section

• Links and FAQ section

• Provider Login section

mailto:[email protected]


Important State Websites

10/9/2017 Family Planning Workshop

STATE WEBSITE:

PROGRAM POLICY MANUAL

• http://www.hsd.state.nm.us/mad/policymanual.html

BILLING INSTRUCTIONS

• http://www.hsd.state.nm.us/mad/billinginstructions.html

REGISTERS AND SUPPLEMENTS:

• http://www.hsd.state.nm.us/mad/registers/2012.html

http://www.hsd.state.nm.us/mad/policymanual.html

http://www.hsd.state.nm.us/mad/billinginstructions.html

http://www.hsd.state.nm.us/mad/registers/2011.html

IMPORTANT!

Electronic Funds Transfers (EFT)

Glossary Of Terms

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Glossary of TermsVisit the link below for a list of frequently used abbreviations.

http://www.hsd.state.nm.us/LookingForInformation/Glossary_of_Abbreviations.aspx

http://www.hsd.state.nm.us/LookingForInformation/Glossary_of_Abbreviations.aspx

History of MedicaidAs he campaigned in 1964 Lyndon B. Johnson declared a “The War on Poverty.” He challenged Americans to build a

“Great Society” that eliminated the troubles of the poor.

Medicaid was created by the Social Security Amendment of 1965 which added Title XIX to the Social Security Act.

What is Medicaid?• U.S. health coverage program for individuals and families with low incomes/resources.

• Medicaid is jointly funded by the federal and state governments and administered by the States.

• Largest funding source for health related services for low income people.

It All Fits Together

New Mexico Medicaid Program

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New Mexico Medicaid Program• The Medical Assistance Division (MAD) of the Human Services Department (HSD) administers the Medicaid

program for the State of New Mexico and establishes policies around benefits and claims processing.

• Medical Assistance Division (MAD) is comprised of the Director’s Office and several bureaus or units. To find out

more about each office, bureau, or unit go to the following link

http://www.hsd.state.nm.us/mad/HBureauListing.html

http://www.hsd.state.nm.us/mad/HBureauListing.html

Medicaid Policy Manual• Medicaid Policy Manuals are available for reference.

• Each manual contains basic Medicaid policy as well as specific provider type policy and billing instructions.

• Billing providers should become familiar with their manual and refer to it.

http://www.hsd.state.nm.us/mad/RPolicyManual.html

http://www.hsd.state.nm.us/mad/RPolicyManual.html

What is HIPAA?

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HIPAA Is?

The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996

(HIPAA, Title II) required the Department of Health and Human Services (HHS) to establish national standards for

electronic health care transactions and national identifiers for providers, health plans, and employers.

HIPAA Is?

The security and privacy of health data was also addressed. As the industry adopts these standards for the efficiency

and effectiveness of the nation's health care system, the use of electronic data interchange will improve.

• NPI (National Provider Identifier)

• Electronic Billing (Payer Path, Clearing Houses)

• NM Medicaid Web Portal

New Mexico Medicaid Program

Eligibility: Who qualifies?

Client eligibility is determined by the Income Support Division (ISD) of HSD or Social Security Office

Eligibility is based upon family size, income, assets and other criteria (Often in association with the disability or

age of an individual)

Clients qualify for Medicaid under a specific category of eligibility (COE). The COE can also indicate a benefit

package (full benefits, limited benefits, full benefits but may owe co-pays, etc.)

How to Apply for Medicaid Benefits

In order to apply, clients must provide information about family, income, and assets to the ISD office in their local

county, or if their eligibility is determined by the Social Security Department, the information is reported to the Social

Security Department.

How to Apply for Medicaid Benefits

Once approved clients receive a blue plastic Medicaid ID card upon their eligibility being sent to Conduent.

*The card itself is not proof of eligibility. Rather the card contains information that enables a provider to check on eligibility. In

addition, a provider should always ask to see other recipient identification in order to assure that the patient is who he or she claims

to be.

• Remember to verify that eligibility is current.

• Clients must inform their caseworker of any status changes.

NM Medicaid Blue Card

Ways to Check Eligibility•On-Line Eligibility Inquiry—Web Portal

https://nmmedicaid.portal.conduent.com/static/index.htm

•Automatic Voice Response System (AVRS) (800) 820-6901

•Conduent Eligibility Help Desk: (800)-705-4452

Monday, Tuesday, Wednesday and Friday 8:00 a.m. - 5:00 p.m.

Thursday (Mountain Time) 8:00 a.m. - 4:00 p.m.


Medicaid Recipient COE Examples072: Medicaid full benefits

035: Pregnancy-related services only

029: Family Planning Benefits

074: Working Disabled Individuals

041: QMB - Age 65 and Over

044: QMB - Under 65

For a COE & description listing, go to:

http://www.hsd.state.nm.us/mad/pdf_files/GeneralInfo/Eligpamphlet.pdf

http://www.hsd.state.nm.us/mad/pdf_files/GeneralInfo/Eligpamphlet.pdf

New Mexico Medicaid Program Structure

NM Medicaid Managed Care Organizations

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SALUD!The managed care contracts provide for the delivery of medically necessary physical and behavioral health services to

approximately 300,000 children and adults in New Mexico.

SALUD!Native Americans are not automatically enrolled in SALUD!, however, they can choose to be in SALUD!

Visit the link below for additional details regarding the Native American opt-in policy.

http://www.hsd.state.nm.us/mad/PNaoptin.html

Medicaid clients who are dual eligible (covered by Medicare and Medicaid) are enrolled in CoLTS and not SALUD!.

http://www.hsd.state.nm.us/mad/PNaoptin.html

SALUD!Medicaid clients qualified under COE 029 – Family Planning Services Only are not in SALUD!.

Medicaid clients in nursing homes or intermediate care facilities for the developmentally disabled are enrolled in

CoLTS.

SALUD!• Clients not excluded from SALUD! are enrolled in SALUD! about 4-6 weeks after they’ve qualified for Medicaid.

During that 4 - 6 week interval, most recipients are in the Medicaid Fee-For-Service Program with claims processed

by Conduent.

• The client receives a notice that they will be enrolled in SALUD! and have an opportunity to select their MCO.

• If they do not select a MCO by a certain date, they are automatically assigned to a MCO. The client has 90 days

after assignment to change their SALUD!.

SALUD!• A newborn baby is enrolled in the same MCO as the mother, if the mother was enrolled in SALUD! on the baby’s

date of birth.

• The baby’s birth must be reported to the ISD office for the enrollment to take place.

SALUD! Managed Care Organizations (MCO)• Lovelace Healthcare: 800-808-7363

• Molina Healthcare: 800-580-2811

• Presbyterian Healthcare: 888-977-2333

• Blue Cross Blue Shield of NM: 866-689-1523

Coordination of Long Term Services (CoLTS)CoLTS covers primary, acute, and long-term services in one coordinated and integrated program that incorporates

Medicare and Medicaid services.

Clients who are also eligible for Medicare and are in nursing facilities, or receive certain services such as Personal

Care Option services in their home, are enrolled in a CoLTS MCO, not in Salud!

CoLTS MCO:

• United Healthcare: 800-851-1878

• Amerigroup: 800-600-4441

Important Reminder• In all cases, providers must be enrolled in the MCO in order to be paid by the MCO.

• Providers must follow MCO requirements and submit claims to the MCO for clients who are enrolled in SALUD! orCoLTS on the date(s) of service (DOS).

• Conduent cannot pay physical health claims for clients enrolled in SALUD! or CoLTS on the claim’s DOS.

NM Medicaid Structure: Fee-for-Service (FFS)

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NM Medicaid Structure Fee-for-Service (FFS)Conduent is the Fiscal Agent for the New Mexico Medicaid Fee for Service program.

NM Medicaid Structure Fee-for-Service (FFS)Clients who are not enrolled in SALUD! or CoLTS may obtain health care services from any provider who accepts

Medicaid.

This part of the Medicaid program is referred to as Medicaid “fee-for-service”.

NM Medicaid Structure Fee-for-Service (FFS)Terms you may hear describing clients in the Medicaid fee-for-service program:

“exempt”

“Medicaid fee-for-service”

“In regular Medicaid”

“Medicaid traditional”

As the Fiscal Agent

•

•

•

•

The Fiscal Agent Does Not:

•

•

Full Medicaid Covered Services through Fee-for-Service (FFS) Medicaid

Insure New Mexico Programs

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2012 Federal Poverty Level Guidelines

Behavioral Health Services

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Behavioral Health ServicesServices provided by a Behavior Health Provider are administered by Optumhealth.

Prescription drugs prescribed by a Behavioral Health Provider are also administered by OptumHealth.

It is the provider type, not the service or the diagnosis that is used to determine if it is Behavioral Health Service.

For clients enrolled in CoLTS, Medicare crossovers are paid by the CoLTS MCOs (Amerigroup, UnitedHealthcare).

Behavioral Health ServicesBehavioral Health Providers should access Optumhealth’s website for information.

https://www.optumhealthnewmexico.com

https://www.optumhealthnewmexico.com/

NM Medicaid Utilization Review

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Utilization Review (UR)Prior Authorization (PA)

• Some services in the Fee For Service program require prior authorization in order for the claim to be eligible

for payment.

• The PA is issued based upon medical necessity, but does not guarantee the client’s Medicaid eligibility.

(Eligibility must still be verified).

Utilization Review (UR)The UR contractor for New Mexico is Molina TPA (Third Party Assessor)

All claims for Waiver and PCO providers require an authorization.

• Waiver providers – Contact the Case Manager to obtain or follow up on a Prior Authorization.

PCO providers – Contact Molina TPA (Third Party Assessor).

(505) 348-0311 ( in Albuquerque)

(866) 916-3250 (Toll free)

Utilization Review (UR)How do you determine if/when a Prior Authorization (PA) is required?

Call Molina. They can tell you if a PA is required and the procedures for getting a Prior Authorization.

Molina TPA (Third Party Assessor)

• (505) 348-0311 ( in Albuquerque)

• (866) 916-3250 (Toll free)

• Also, consult the Medicaid program and policy manuals and billing manuals for prior authorization requirements.

Authorizations for EMSA Emergency Medical Service for Aliens (review contact Molina TPA.).

Utilization Review (UR)Out of State Providers - When submitting a claim on the CMS-1500 claim form for a New Mexico Medicaid client, please attach the Prior Authorization to the claim. If the

claim is submitted with the Prior Authorization number located in form locator 23, the claim will deny. Reminder: all out of state providers require a prior authorization for

services rendered to a New Mexico Medicaid client.

Dental Providers need to submit requests for prior approval to:

DentaQuest USA, LLC

12121 North Corporate Parkway

Mequon, WI 53092

If you have questions or concerns, regarding your prior approval requests that have been submitted to DentaQuest for review,

please contact DentaQuest Customer Service at: 1-800-417-7140 (toll free)

Medicaid Management Information System (MMIS)

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Medicaid Management Information System (MMIS)Medicaid Management Information System (MMIS). Omnicaid is the name of New Mexico's MMIS.

Conduent maintains Omnicaid to process claims and issue payments to Medicaid providers for their services to Medicaid clients.

Some data that MMIS contains includes provider information, client information, claims history, and payment history.

NM Medicaid Web Portal

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The Conduent New Mexico Medicaid Portalhttps://nmmedicaid.portal.conduent.com/static/index.htm


Categories of Eligibility with Limited Benefits

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029 – Family Planning Which services are covered?

Medical Claims and Institutional Claims:

The system examines the revenue code, procedure code, and any related diagnosis codes on the line. The service is

covered by the Family Planning Medicaid (FPM) if a combination of the approved code sets are used to identify the

service:

• Procedure Code and the diagnosis codes must be contraceptive management or screening and treatment for

sexually transmitted diseases.

Institutional Claims only:

• The revenue code and diagnosis are on the approved code lists.

.

029 – Family Planning • Treatment of conditions not related to contraception, sterilization, or sexually transmitted diseases.

Hysterectomies for the sole purpose of sterilization and pregnancy terminations are not covered.

0029 – Service Not Family Planning Related Why does this denial occur when the service was actually for Family Planning?

• Procedure code, diagnosis code, or revenue code not recognized as family planning related. If renderedservice is family planning related, resubmit claim using alternate codes. You can verify if a code is coveredby contacting the Provider Relations Help Desk. Do not bill Medicaid client for services that can be billedusing an alternate approved codes.

• If you are not able to locate a suitable alternative code for your service but feel the service should be paidunder this benefit package, please contact the FPM Program Manager at MAD.

0035 – Pregnancy Related (Presumptive) Covered Services

Presumptive: Presumptive Eligibility (PE) is short-term (60 days or less) Medicaid coverage for children up to age 19

or for pregnant women.



covered by Pregnancy Related Services Only (PRSO) if a combination of the code sets are used to identify the service:

Procedure Code and the diagnosis code are relating to a pregnancy or complications of pregnancy.

Note: Inpatient stay not covered under presumptive eligibility, the individual must first complete the eligibility

process

0035 – Pregnancy Related (Presumptive Non-Presumptive) Covered Services



covered by Pregnancy Related Services Only (PRSO) if a combination of the code sets are used to identify the service:

• Procedure Code and the diagnosis code are relating to a pregnancy or complications of pregnancy and

conditions that may complicate the pregnancy.

Institutional Claims only:

• The revenue code and diagnosis are relating to a pregnancy or complications of pregnancy and conditions that may

complicate the pregnancy.

041,044 – Qualified Medicare Beneficiary (QMB)MEDICAID covers the co-insurance and deductible on MEDICARE covered services only after MEDICARE has paid.

If service is not covered by MEDICARE,

MEDICAID WILL NOT PAY.

Categories of Eligibility with Co-Pays• 071 FM 1 – CHIP (Children’s Health Insurance Program)

• 074 – WDI (Working Disabled Individuals)

Clients with these COEs may owe co-pays for some services; Native American Exempt (NAX) clients are excluded

from all co-payments.

Copayment Schedules are available on the Eligibility Inquiry on the Web Portal.

Other Categories of Eligibility

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CMS (Children’s Medical Services)Children’s Medical Services is part of the Family Health Bureau in the Public Health Division of the Department of Health, and is

federally funded through Title V and State General Funds to serve as a safety net for medical management, payment for medical

services, diagnostic studies and service coordination for Children and Youth with Special Health Care Needs (CYSHCN).

CMS is billed similar to regular Medicaid (FFS) with the following differences:

• Always use the 14 digit CMS client ID number that begins with 07 off of the MAD 309 form

• Always enter the PA number in box 23 of the CMS-1500 form (If the PA number is 8 digits, add 2 zeroes in front of it.)

All claims for Children’s Medical Services (CMS) clients must have the CMS prior authorization number entered on the claim.

CMS (Children’s Medical Services)CMS claims can be submitted electronically. However, if the claims denies for eligibility, submit the claim on paper and

attach the paper authorization issued by CMS, which is either the CMS 309 form, CMS Card letter or CMS

Registration.

If a CMS PA for a pharmacy service is not on file, the provider needs to first contact the Point of Sale Helpdesk and

then fax the CMS PA to them:

• Point of Sale Helpdesk

800-365-4944

Prior Authorization

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Prior Authorizations for Pharmacy Claims• Point of Sale Helpdesk

800-365-4944

What do I do if I Get a Denial Pertaining to a Prior Authorization?

Access the Web Portal’s Prior Authorization inquiry.

• Verify the PA/Claim discrepancy the denial pertains to.

• Make claim corrections or follow up with your respective authorizing agency to have PA information

changed/corrected.

Timely Filing

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Timely Filing Limits90 days from the date of service for all providers.

Exceptions to the 90 day timely filing limit:

• Schools, the filing limits are 120 days for the initial filing period and 120 days for the grace period (rather than 90

days).

• IHS and Tribal 638 compact facilities, the filing limit is 2 years from the date of service with no additional grace period.

Timely Filing Limits• For a claim which met the initial filing period, but was denied, partially denied, or requires an adjustment, there is an

additional one-time 90 day grace period counted from the date of payment or denial, during which the claim can be

re-filed or an adjustment submitted to Conduent.

• It is to the provider’s advantage to resubmit a claim, if necessary, within the initial 90 day filing period in order to

have the greatest amount of time in which to re-file or submit an adjustment during the 90 day grace period if

another re-filing or adjustment is necessary.

Timely Filing Limits• The claim may be re-filed during the 90-day grace period as many times as necessary, but claims filed after the 90

day grace period will be denied.

Timely Filing LimitsExceptions to the filing limit:

When other primary payers have denied or made payment on a claim, the filing limit of 90-days is counted from the

date of payment or denial by the other party, but not to exceed 210 days from the date of service. A provider should file

claims in sufficient time with other payers to allow submission in time to meet the Medicaid 210 day limit.

When the recipient has retroactive eligibility, the initial filing limit is 120 days from the date the eligibility was added to

the eligibility file and was therefore available to providers.

Timely Filing DenialsExceptions to the filing limit:

When the provider was not originally enrolled as a MAD provider on the date of service, the filing limit of 90 days is

counted from the date the provider was notified of their enrollment, but must not exceed 210 days from the date of

service. A provider should submit a provider participation agreement in sufficient time to allow processing and still

meet the Medicaid 210 day limit for submitting the claim.

When a claim previously paid by a Medicaid managed care organization is recouped from a provider due to retroactive

disenrollment of the client from the managed care organization, the filing limit of 90 days is counted from the date of

the managed care organization’s notice or recoupment from the provider.

Timely Filing DenialsRe-filing Claims and Submitting Adjustments

When resubmitting a claim or requesting an adjustment on a claim that is past the 90 day filing limit but originally met

the filing limit, the “TCN” number which appears on the remittance advice (RA) will be used by Conduent to evaluate

the claim. The provider must supply that TCN number in order for Conduent to be able to evaluate the claim.

Timely Filing Denials

Re-filing Claims and Submitting Adjustments

CMS 1500 form: Put the TCN in block 22 on the paper form. Leave the “Code” blank, and put the TCN in the “Original

Reference No.” field.

UB Form: Put the TCN in Form Locator 64 “Document Control Number” (DCN) matching the appropriate payer line,

using a paper form.

Dental Claim Form: Enter the TCN number in Box 35 beginning on the left side.

Timely Filing Helpful HintsThere are two filing limits to meet - the initial filing limit and the grace period limit. Continuing to re-file a claim does not

continue to extend the filing limit. It is to the provider’s advantage to file or request an adjustment on the most recently

filed claim that met the original filing limit.

• When requesting an adjustment on an adjusted claim, use the TCN of the final payment or denial, not the credit

record which has a negative amount on the RA.

• The filing limit does not apply when the provider is returning an overpayment to the Medicaid program.

• When submitting a paper claim each claim needs a cover letter and any necessary attachments explaining what the

claim.

Electronic Claim Submissions

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Electronic Claim SubmissionAll Fee For Service claims within 90 days from the initial date of service that do not require an attachment for paymentmust be submitted electronically.

For any assistance regarding Electronic Claims Submissions, contact the HIPAA Helpdesk.

[email protected]

or call 800-299-7304


Three Ways to Submit Electronically• PayerPath – Free HIPAA Compliant web-based claims entry system.

The URL to the registration form for PayerPath submissions is: http://www.hsd.state.nm.us/mad/hipaa.html

*Pay attention to the RA Newsletter, for upcoming updates to PayerPath.

• Through a Clearinghouse

• EDI Gateway

The URL for additional information regarding EDI Gateway electronic submissions is:

http://www.hsd.state.nm.us/uploads/files/Providers/Manuals%20and%20Guides/HIPAA%20Standard%20Transactions%20Companion%20Guides/EDI%20Submission%20Procedures/Converting%20from%20TIE%20to%20Conduent%20EDI%2010-19-17%20(Final).pdf

http://www.hsd.state.nm.us/mad/hipaa.html

http://www.hsd.state.nm.us/uploads/files/Providers/Manuals and Guides/HIPAA Standard Transactions Companion Guides/EDI Submission Procedures/Converting from TIE to Conduent EDI 10-19-17 (Final).pdf

Claim Form Instructions

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Where to Get a Copy of Claim Form Instructions

Claim Reference Tools

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What is a Transaction Control Number (TCN)?The TCN is a unique number assigned to each and every claim. This number contains information about the claim andcan be used to identify the claim when calling provider services.

What is a Transaction Control Number (TCN)?

Claim Follow UpCheck for claim status on the Web Portal.

• Claim specific search capability is available using the web portal to locate specific claims quickly.



Claim Follow Up Reading the Remittance Advice (RA)The Remittance Advice, also known as an Explanation of Benefits (EOB), is produced weekly.

The RA lists Claims Conduent has processed for a particular provider, explaining which claims are pending, paid, or

denied, and the reason for any denials.

A financial summary is also included in the RA.

introduction to nm medicaid · call molina. they can tell you if a pa is required and the...

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